- Rotator cuff tears can be caused by extrinsic factors like repetitive use or impingement, or intrinsic factors like changes in tendon vascularity or degenerative changes. - Physical examination involves inspection, palpation, range of motion testing and muscle strength testing. Investigations include ultrasound and MRI. - Symptomatic rotator cuff tears tend to increase in size over time if left untreated, especially in younger patients under 60 years old. - Surgery is indicated for failed conservative treatment, significant weakness, or acute tears in young active patients. - Arthroscopic repair has advantages over open repair like less pain and blood loss, but requires special instruments and equipment. -

1. Prof. Bijayendra Singh
Consultant Trauma & Orthopaedic Surgeon
Medway NHS Foundation Trust
Visiting Professor, Canterbury Christ Church University
Cuff Repair

2. What is Rotator cuff ?

3. Extrinsic Factors
• Repetitive use
• Glenohumeral instability
• Internal impingement
• Impingement
• Acromial spurs
• Coracoacromial ligament
• AC joint osteophytes
• Coracoid process
• Posterior superior glenoid
Acute Trauma

4. Intrinsic Factors
• Vascular supply (? significance)
• Distal 1cm of supraspinatus tendon (early studies)
• Hypervascularity with tendonitis
• Codman (1934) described critical zone
• Rathburn (1970) position related to blood supply
• Lohr (1990) bursal side better blood supply :
Increased incidence of articular surface tears?
• Degenerative changes
• Age related
• Change in proteoglycan and collagen content in
symptomatic tendons

5. Physical Examination
• Inspection: Atrophy, symmetry
• Palpation: AC joint, cuff tenderness
• Range of motion: Active, passive
• Muscle strength
• Special tests

6. Investigations

7. • Ultrasound:
• High Accuracy for Full
Thickness Tear
• Poor info on other
pathologies
• Static images for
dynamic investigation
• Operator Dependent
• MRI:
• Gold Standard
• Easier to explain to patient
• Other Shoulder Pathologies
• Muscle Atrophy
• Expensive/Cumbersome
• May find pathologies of no
clinical relevnace..

8. Natural History
• Asymptomatic: 5 - 40%
• Increases with age

9. • Sher et al, J Bone Joint Surg Am. 1995 Jan;77(1):10-5:
Abnormal MRI Findings in asymptomatic shoulders
• 96 asymptomatic shoulders MRI
• 14 FT & 19 PT
• > 60: 28% FT, 26% PT (54%)
• 40 - 60: 4% FT, 24% PT (28%)
• < 40: no FT, 4% PT

10. Pain and/or
fatigue of cuff
Rotator Cuff
dysfunction
Impingement with
motion

11. Indications for Surgery
• Failed conservative management
• Significant or progressive weakness
• Young, active
• Acute tear
• Early repair if age<50 years and full-thickness tear

12. • Do we need to repair
Open vs Arthroscopic

13. Do we need to Repair Cuffs?

14. Natural History of Non operatively Treated Symptomatic Rotator Cuff
Tears in <60 yrs. (5mm or more)
Safran et al: Am Jr. Sports Medicine, 39(4), 710 - 714
• F/U: 25 - 39 months
• Ultrasonography by same sonographer
• 51/61 evaluated
–30 (49%) tears increased in size
–26 (41%) no change
–5 (8%) reduced
–10(25%) found to have new tears
• No correlation between change in tear size,
–patient age
–prior trauma
–size of tear at index
• Co-relation between considerable pain & increase in tear size

15. Open Vs Arthroscopic

16. Open Repair
• Advantages:
• Easy
• No special equipment required
• Direct visualization of cuff repair and acromioplasty
• Good long term follow-up. Several studies with >10
year follow-up show generally stable results with
time
• UKCUFF Trial

17. Disadvantages
• Deltoid detachment required
• Increased perioperative morbidity
• Unrepairable tear will be opened
• Significant intraarticular pathology can be missed
• Increased blood loss
• Increased rehabilitation time
• Large scar

18. Arthroscopic Cuff Repair
• Deltoid preservation
• Diagnosis and treatment of any concomitant shoulder
pathology
• Decreased postoperative pain
• Decreased blood loss
• Small surgical scar
• Shorter hospital stay
• Earlier rehabilitation
• Decreased postoperative stiffness

19. Disadvantages
• Special Instruments
• Cannula
• Suture Passer
• Suture manipulator
• Appropriate Anchors
• Suture Cutter
• Suture Management
Learning Curve

21. Principles of Repair
• Neer JBJS-A 1972
• Adequate subacromial decompression
• Repair tendon to bone
• Secure fixation of tendon to tuberosity
• Mobilization of muscle-tendon units
• Closely supervised rehabilitation

22. Single Row vs Double Row

26. Biomechanics
• Single Row - 220 N
• Double Row - 320 N
• Suture Bridge - 20 - 50% higher
• Almost all biomechanical studies show lower re-tear
rates for double row / Suture Bridge

27. Clinical Outcomes
• Franceschi et al:
• 30 in each group, UCLA 32.9 vs 33.3 post op
• MRI retear = 12/16 single, 8/26
• Burks et al:
• 20 in each group, No difference in UCLA, ASES, Constant
• Retear 2 in each on MRI
• Grasso et al
• 40 in each group
• No significant difference in DASH, Constant & Muscle Strength
• No post op imaging
Level 1 studies

28. Rehabilitation
• Four Phases
• Inflammatory: 7 days
• Proliferative: 2 - 3weeks
• Healing Phase: 3 - 12 weeks
• Maturation: 12 - 26 weeks

32. Ross et al: Rehabilitaiton Following Arthroscopic Rotator Cuff Repair - Review of
Current Literature. JAAOS, 2014, 22(1), 1 - 9
• ROM:
• Some studies have shown better elevation in early stages
• Preop ROM important factor
• NO difference at one year
• Pain:
• No significant difference in early vs late mobilisation
• Muscle Strength:
• No difference, significantly lower than other side
• Re Tear Rates:
• 0 - 94%
• Variable results on radiological re-tears
• No functional difference

33. Enhancement
• Biology of patient & tendon (can’t be altered)
• Techniques:
• Microfracture of healing bed
• Use of vented anchors
• Doxycycline (reduces effects of MMP)
• PRP
• Mesenchymal stem cells
• No definite evidence at present

34. Conclusion
• Keys to success:
• Pick a winner
• Good anaesthesia
• Tension-free reduction
• Thorough bursectomy for visualisation
• Work to a system
• Variety of equipment invaluable
My choice
• Small Tears = Single Row - Mattress Repair
• Large > 3 cm = Double Row - Suture-bridge technique

35. Thank You